862 UNIT VIII / Responses to Altered Cardiac Function

CHART 29–3 NANDA, NIC, AND NOC LINKAGES

The Client with a Dysrhythmia
NURSING DIAGNOSIS NURSING INTERVENTIONS NURSING OUTCOMES
• Activity Intolerance • Energy Management • Activity Tolerance
• Self-Care Assistance • Self-Care: ADL
• Anxiety • Anxiety Reduction • Anxiety Control
• Decreased Cardiac Output • Cardiac Care: Acute • Cardiac Pump Effectiveness
• Cardiac Precautions • Circulation Status
• Deficient Knowledge • Teaching: Disease Process • Knowledge: Disease Process
• Teaching: Procedure/Treatment • Knowledge: Treatment Procedure(s)
• Ineffective Tissue Perfusion • Dysrhythmia Management • Cardiac Pump Effectiveness
• Vital Signs Monitoring • Vital Signs Status
Note. Data from Nursing Outcomes Classification (NOC) by M. Johnson & M. Maas (Eds.), 1997, St. Louis: Mosby; Nursing Diagnoses: Definitions & Classification 2001–2002 by
North American Nursing Diagnosis Association, 2001, Philadelphia: NANDA; Nursing Interventions Classification (NIC) by J.C. McCloskey & G. M. Bulechek (Eds.), 2000, St. Louis:
Mosby. Reprinted by permission.

effort focuses on coping strategies and lifestyle changes, as
well as specific management of prescribed therapies. Include
the following topics as appropriate when teaching the client
and family for home care.
• Function, maintenance, precautions, and signs of malfunc-
tion or complications of any implanted device such as a pace-
maker or ICD
• Monitoring pulse rate and rhythm
• Activity or dietary restrictions, and any potential effects of
the dysrhythmia or its treatment on lifestyle
• Medication management to reduce the risk of dysrhythmias,
including the desired and potential adverse effects of anti-
dysrhythmic drugs
• Specific instructions related to planned diagnostic tests or
procedures
• The importance of follow-up visits with the cardiologist
• The importance of and where to obtain CPR training for the
client and family members
In addition, discuss fears related to treatment or implanted
devices, such as that of shocking a significant other during
close contact or sexual activity. Explain that if a shock occurs,
the partner may feel a slight buzz or tingling but should not be
harmed. Refer to and encourage the client and family to attend
a peer support group for the specific condition.

Nursing Care Plan

A Client with Supraventricular Tachycardia
Elisa Vasquez, 53 years old, is admitted to the DIAGNOSIS
cardiac unit with complaints of palpitations, light- Ms. Lewin formulates the following nursing diagnoses for Ms.
headedness, and shortness of breath. Her history reveals rheu- Vasquez.
matic fever at age 12 with subsequent rheumatic heart disease • Decreased cardiac output related to inadequate ventricular fill-
and mitral stenosis. An intravenous line is in place and she is re- ing associated with rapid tachycardia
ceiving oxygen. Marcia Lewin, RN, is assigned to Ms. Vasquez. • Ineffective tissue perfusion: cerebral/cardiopulmonary/peripheral
related to decreased cardiac output
ASSESSMENT • Anxiety related to unknown outcome of altered health state
Ms. Lewin’s assessment reveals that Ms. Vasquez is moderately
anxious. Her ECG shows supraventricular tachycardia (SVT) with a EXPECTED OUTCOMES
rate of 154.Vital signs:T 98.8° F (37.1° C), R 26, BP 95/60. Peripheral The expected outcomes for the plan of care specify that Ms.
pulses weak but equal, mucous membranes pale pink, skin cool Vasquez will:
and dry. Fine crackles noted in both lung bases. A loud S3 gallop • Maintain adequate cardiac output and tissue perfusion.
and a diastolic murmur are noted. Ms.Vasquez is still complaining • Demonstrate a ventricular rate within normal limits and stable
of palpitations and tells Ms. Lewin,“I feel so nervous and weak and vital signs.
dizzy.” Ms.Vasquez’s cardiologist orders 2.5 mg of verapamil to be • Verbalize reduced anxiety.
given slowly via intravenous push and tells Ms. Lewin to prepare • Verbalize an understanding of the rationale for the treatment
to assist with synchronized cardioversion if drug therapy does not measures to control the heart rate.
control the ventricular rate.
 CHAPTER 29 / Nursing Care of Clients with Coronary Heart Disease 863
Nursing Care Plan
A Client with Supraventricular Tachycardia (continued)
PLANNING AND IMPLEMENTATION
Ms. Lewin plans and implements the following nursing interven-
tions for Ms. Vasquez.
• Provide oxygen per nasal cannula at 4 L/min.
• Continuously monitor ECG for rate, rhythm, and conduction.
Assess vital signs and associated symptoms with changes in
ECG. Report findings to physician.
• Explain the importance of rapidly reducing the heart rate.
Explain the cardioversion procedure and encourage questions.
• Encourage verbalization of fears and concerns. Answer ques-
tions honestly, correcting misconceptions about the disease
process, treatment, or prognosis.
• Administer intravenous diazepam as ordered before cardio-
version.
• Document pretreatment vital signs, level of consciousness, and
peripheral pulses.
• Place emergency cart with drugs and airway management sup-
plies in client unit.
• Assist with cardioversion as indicated.
• Assess LOC, level of sedation, cardiovascular, and respiratory
status, and skin condition following cardioversion.
• Document procedure and postcardioversion rhythm, and re-
sponse to intervention.
EVALUATION
Intravenous verapamil lowers Ms.Vasquez’s heart rate to 138 for a
short time, after which it increases to 164 with BP of 82/64. Her
THE CLIENT WITH SUDDEN CARDIAC DEATH
Sudden cardiac death (SCD) is defined as unexpected death
occurring within 1 hour of the onset of cardiovascular symp-
toms. It usually is caused by ventricular fibrillation and cardiac
arrest. Cardiac arrest is the sudden collapse, loss of conscious-
ness, and cessation of effective circulation that precedes bio-
logic death. Nearly half of all cardiac arrest victims die before
reaching the hospital; only 25% to 30% of out-of-hospital car-
diac arrest victims survive to be discharged (Woods et al.,
2000).
Almost 50% of all deaths due to coronary heart disease are
attributed to SCD. Coronary heart disease (CHD) causes up to
80% of all sudden cardiac deaths in the United States. Other
cardiac pathologies such as cardiomyopathy and valvular dis-
orders also may lead to SCD. Noncardiac causes of sudden
death include electrocution, pulmonary embolism, and rapid
blood loss from a ruptured aortic aneurysm.
Ventricular fibrillation is the most common dysrhythmia as-
sociated with sudden cardiac death, accounting for 65% to 80%
of cardiac arrests. Sustained severe bradydysrhythmias,
asystole or cardiac standstill, and pulseless electrical activity
(organized cardiac electrical activity without a mechanical re-
sponse) are responsible for most remaining SCDs (Braunwald
cardiologist, Dr. Mullins, performs carotid si-
nus massage. The ventricular rate slows to 126
for 2 minutes, revealing atrial flutter waves, and then returns to a
rate of 150. Dr. Mullins explains the treatment options, including
synchronized cardioversion. Ms.Vasquez agrees to the procedure.
Ms. Vasquez is lightly sedated and synchronized cardioversion
is performed. One countershock converts Ms. Vasquez to regular
sinus rhythm at 96 BPM with BP 112/60.
Ms. Vasquez is sleepy from the sedation but recovers without
incident. She states that she feels “much better,” and her vital
signs return to her normal levels. She remains in NSR with a rate
of 86 to 92 for the remainder of her hospital stay. Dr. Mullins
places Ms.Vasquez on furosemide to treat manifestations of mild
heart failure.
Critical Thinking in the Nursing Process
1. What is the scientific basis for using carotid massage to treat
supraventricular tachycardias? Was this an appropriate ma-
neuver in the case of Ms. Vasquez?
2. What other treatment options might the physician have used
to treat Ms. Vasquez’s supraventricular tachycardia if she had
been asymptomatic with stable vital signs?
3. Develop a teaching plan for Ms. Vasquez related to her pre-
scription for furosemide.
See Critical Thinking in the Nursing Process in Appendix C.
et al., 2001). Selected cardiac and noncardiac causes of sudden
cardiac death are listed in Box 29–6.
Risk factors for SCD are those associated with coronary
heart disease (see the next section of this chapter). Advancing
age and male gender are powerful risk factors. After age 65, the
gap between male and female incidence of SCD narrows
(Braunwald et al., 2001). Clients with dysrhythmias such as re-
current VT may have a higher risk of SCD.
PATHOPHYSIOLOGY
Evidence of coronary heart disease with significant atheroscle-
rosis and narrowing of two or more major coronary arteries is
found in 75% of SCD victims. Although most have had prior
myocardial infarction, only 20% to 30% have recent acute my-
ocardial infarction. An acute change in cardiovascular status
precedes cardiac arrest by up to 1 hour; however, often the on-
set is instantaneous or abrupt. Tachycardia develops, and the
number of PVCs increase. This is followed by a run of ventric-
ular tachycardia that deteriorates into ventricular fibrillation
(Braunwald et al., 2001).
Abnormalities of myocardial structure or function also con-
tribute. Structural abnormalities include infarction, hypertro-
phy, myopathy, and electrical anomalies. Functional devia-
tions are caused by such factors as ischemia followed by
reperfusion, altered homeostasis, autonomic nervous system